Research to improve rural community health
In this day and age, not many people can say they have devoted almost three decades of their life to a particular project or cause. Then again, Professor Steve Tollman is no ordinary man. Since taking over as the director of Wits University’s Health Systems Development Unit in 1990, he has worked tirelessly to establish a high-functioning platform and data infrastructure to conduct research into the health and wellbeing of rural populations in South Africa.
“Tackling health and development effectively is critical to the livelihoods of rural South Africans,” explains Tollman. “They carry the greatest burden of illness, which undermines their personal development and economic and social productivity.
“The grand challenge is bridging this massive evidence gap to inform policy development and innovation, and assess its resulting impact.”
Tollman’s approach was to introduce detailed and sustainable research into the overall health and wellbeing of South Africa’s rural communities, as well as to determine any underlying causal factors – environmental, socio-economic, behavioural and physiological.
“Without the necessary data, public sector investments tend to be ‘hit or miss’, yet their potential to support human development and livelihoods is immense,” says Tollman. “To achieve a step-change, it is vital to introduce robust and sustainable research infrastructures. Indeed, the best science and technology are justified where needs are greatest.”
Inspiration came from the experience of world-leading research platforms in Bangladesh and Senegal, addressing cholera and measles, respectively. The pioneering efforts of the late Dr Sidney and Emily Kark in social medicine in South Africa were also to form the basis of what is now termed “community-oriented primary care”. Tollman’s early steps involved motivating national and international funders to provide seed resources to evaluate innovative, decentralised services in nutrition, reproductive health, mental health and primary care. The resultant research added much-needed insight that later contributed to the government’s national health strategy.
Tollman went on to create a versatile and robust health and socio-demographic surveillance system (HDSS) that covered the Agincourt sub-district of Mpumalanga. This involved creating on-the-ground teams, who were tasked with itemising and updating household membership, deaths, births and migrations. They focused predominantly on the health and wellbeing of children, adolescents and young and older adults.
The resultant data was then analysed to capture health and population trends, as well as launch vital intervention studies to address rural health and development priorities.
“Establishing the HDSS research infrastructure involved continuous evaluation and innovation in prototype methods,” explains Tollman. “‘Verbal autopsies’ were used to establish probable cause of death by interviewing the caregiver during a patient’s terminal illness. This is vital as up to 50% of rural deaths occur outside of clinics and hospitals. ‘Migration reconciliation’ was needed to record temporary/labour migration. Then there was the challenge of transferring paper-based data to an electronic-data system.”
The Agincourt platform is unique on the continent and provides much-needed information on the changing population and health profile in rural communities. As Tollman says: “There is immense potential to extend efforts and contribute to a more evidence-sensitive, responsive government. An informed citizenry is more empowered to use services while holding authorities to account.”
Tollman’s leadership has been instrumental in establishing the MRC/Wits Rural Public Health and Health Transitions Research Unit. Under his direction, what began as a handful of grant-funded staff has evolved to its current scale and scope, employing more than 300 field staff, supervisors, managers, technical experts and scientists who anchor several multi-year research programmes and a number of smaller projects.
Internationally, Tollman is a guest professor at the Centre for Global Health Research at Umeå University in Sweden, and principal scientist of the International Network for the Demographic Evaluation of Populations and Their Health, aka the INDEPTH Network.